a.

Location
b. Quality
c. Severity
d. Duration
e. Timing
f. Context
g. Modifying Factors
h. Associated Signs and Symptoms

Past Medical History (PMHA review of past illnesses, operations or injuries, which may include:

1. Prior illnesses or injuries

2. Prior operations
3. Prior hospitalizations
4. Current medications
5. Allergies
6. Age appropriate immunization status
7. Age appropriate feeding/dietary status

E/M University Coding Tip: Notice that current medications and allergies are each
considered to be individual elements of Past Medical History
Family History (FH): A review of medical events in the patient’s family which may include information about:

1. The health status or cause of death of parents, siblings and children

2. Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
3. Diseases of family members which may be hereditary or place the patient at risk

Social History (SH): An age appropriate review of the patient’s past and current activities which may include significant
information about:

1. Marital status and/or living arrangements

2. Current employment
3. Occupational history
4. Use of drugs, alcohol or tobacco
5. Level of education
6. Sexual history
7. Other relevant social factors

There are two levels of PFSH :

1. Pertinent PFSH: At least ONE specific item from ANY of the three components of PFSH must be documented.
2. Complete PFSH: A review of two or all three of the PFSH components are required depending on the category
of E/M service

At least ONE item from TWO out of three PFSH components must be documented for a Complete PFSH for:

1)   Established Office Patient

2)   ER visits
3)   Subsequent Nursing Facility Care
4)   Established Patient Domiciliary Care
5)   Established Patient Home Care

At least ONE specific item from THREE of the three components of PFSH must be documented for a Complete PFSH for:

1)   New Office Patient

2)   Hospital Observation Services
3)   Hospital H&P
4)   Consultations
5)   Comprehensive Nursing Facility Assessments
6)   New Patient Domiciliary Care
6)   New Patient Home Care

E/M University CodingTip: Many physicians overlook the fact that some follow-up encounters DO require a review of
the PFSH.  You should carefully review the history requirements for each encounter before selecting and billing any E/M
code.  

E/M University Coding Tip : You DO NOT need to re-record a PFSH if there is an earlier version available on the
chart.  It is acceptable to review the old PFSH and note any changes.  In order to use this shortcut, you must note the date
and location of the previous PFSH and comment on any changes in the information since the original PFSH was recorded. 
For example, if you are seeing an established patient in the office you can say: “Comprehensive PFSH which was performed
during a previous encounter was re-examined and reviewed with the patient.  There is nothing new to add today.  For
details, please refer to my previous note in this chart, dated 11/23/2004.” 

E/M University Coding Tip :  It is not necessary that the physician personally perform the PFSH.  It is acceptable to
have your staff record and document the PFSH or to let the patient fill out a PFSH questionnaire.  However, the physician
MUST state that he or she reviewed the information and comment on pertinent findings in the body of the note.  In addition
the physician should initial the PFSH questionnaire and maintain the form in the chart as a permanent part of the medical
record. 

E/M University Coding Tip : Remember, it only takes ONE element from EACH component of PFSH to qualify for a
complete PFSH.  There is no need to overload the documentation with superfluous information which may not be clinically
relevant. 

1997 Detailed Exam requires at least 12 bullets from any organ systems.

At least 12 bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6

General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)

(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)
Requires two out of three of the following:

1)   Three problem points
2)   Three data points
3)   Moderate risk

Problem POINTS
EXAMPLE 99214

CC : Follow-up hypertension and diabetes

Interval History : The patient’s hypertension has been well controlled on current medications.  Diabetes is stable as well, with
no significant hyperglycemia or episodes of symptomatic hypoglycemia.  Dyslipidemia remains well controlled on statin
therapy.

Medications

Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid

ROS
General - Negative for fatigue, weight loss, anorexia
Cardiovascular - Negative for chest pain, orthopnea or PND
Neurologic - Negative for paresthesias

Pertinent PFSH is remarkable for mild OA which has been quiescent

Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: No peripheral edema

Labs: BUN 12, creatinine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77

Assessment

1. Well controlled Type 2 NIRDM

2. Well controlled hypertension
3. Stable dyslipidemia

Plan

4. Continue current medications unchanged

5. Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
6. Check LFTs at next visit as well due to ongoing statin therapy
7. Continue lifestyle modifications and exercise for weight loss
8. Return visit in four months
What constitutes prescription drug management?
Q. During an evaluation and management visit, what constitutes “prescription drug management?”
A. “Prescription drug management” is based on documented evidence that the provider has evaluated
medications as part of a service, in relation to the patient. This may be a prescription being written or
discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”

Prescription Drug Management

  Bill Dacey
December 29, 2010
 Coding, Billing Compliance

Question: My coder tells me that when I use a prescription medication on a

new problem that I automatically qualify for moderate level decision making.
I'm a pediatrician, and for me this fits a lot of what I feel are lower level
problems. Am I under-coding my services if I bill 99213 with some
prescriptive management?

Answer: Not necessarily. Your coder is referencing the decision-making

tables that Medicare and other payers may use to determine the level of
medical decision making. Technically he or she is correct, but that may not
save you in a medical necessity review. Your instinct seems to me to be
much more in tune with medical necessity.

One of the three tables gives points for the number of problems dealt with:
one point for each established stable problem, two points for a worsening
established problem, and three points for a new problem. We talked about
these in the last issue. There is no issue with a new problem getting you
three points, or moderate complexity, in this table.

The sticky point is the part about writing for a prescription medication. Your
coder is correct that the entry "prescription drug management" is listed in
the "moderate" section. But using this to determine the level of risk is
interpreting the table somewhat mechanically, seemingly without a good
grasp of medical necessity.

The mere presence of prescription drugs does not necessarily qualify for
moderate complexity. CMS has indicated that writing a prescription for a
seven- or 10-day supply of an antibiotic is not considered to be a moderate
level of complexity. At least one Blue Cross company has indicated that
prescription drug management involves more than the use of prescription
drugs. It may mean a change in regimen, the addition of an agent, or the
worsening of a problem. In other words, any prescription is not a guarantee
that a payer will see this your way.

ADVERTISING

Consider the entry in the first column of the table, Presenting Problem, under
low level decision making. It says "acute uncomplicated illness or injury; e.g.,
cystitis, allergic rhinitis, simple sprain." Does the new problem that you were
describing fit into this category? If so, you might be more accurate — as you
indicated — with the low level decision making associated with a 99213.
I'm not trying to diminish your work in any way. I am only saying that a
medical necessity review may find the problem more of a low level one,
despite the fact that a prescription was written. Remember that those tables
were in use as far back as 1990 — almost 20 years ago. The ink may not
have changed on the page, but the interpretation may have moved away
from the literal.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm
dedicated to coding, billing, documentation, and compliance concerns.
Dacey is a PMCC-certified instructor and has been active in physician
training for more than 20 years. He can be reached
at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the January 2010 issue of Physicians

Practice.